2011 International Conference on Family Planning
29 November–2 December 2011
To address the challenges of accessing reproductive health (RH) services, the Kenyan government with support from the German Development Bank has been implementing a RH vouchers program since 2006. The goal is to improve access to adequate RH services, decrease number of maternal and child deaths and increase acceptance of family planning (FP) services among the poor. The theoretical basis of the program is to improve efficiency in service delivery through competition, help target essential health services to vulnerable groups and influence behavior change leading to better maternal outcomes. In Kenya, the first phase was implemented between 2006 and 2008, while the second phase ran from October 2008 to 2011. The vouchers are made available through distributors appointed by the voucher management agency to poor women in Kisumu, Kitui, and Kiambu districts, and in Korogocho and Viwandani informal settlements in Nairobi for comprehensive safe motherhood services and long-term family planning methods at a subsidized cost. Additional vouchers are free for women seeking gender-based violence services.
This paper examines the question of whether the voucher program is associated with higher quality family planning services in facilities that have been accredited since 2006 compared to matched non-voucher facilities.
Health facility assessments were conducted between February and November 2010 in voucher facilities compared to similar non-voucher facilities. Quality of family planning services was assessed using Donabedian’s multi dimensional framework: structure being the attributes of where care is delivered including providers’ technical competence; process to examine whether or not good medical practices are followed; and outcome: impact of the care on health status. The latter is not presented here as the study did not examine health status. To do these, 55 facility inventories and 201 provider interviews were conducted to examine the structural features. In addition, a minimum of six FP provider observations per facility were recorded (n=326) to assess the process elements of care. Analysis entailed cross-tabulations with Chi-square tests to detect significant differences in quality scores between voucher and non voucher facilities.
In terms of structural quality (general infrastructure 0-17 items), voucher facilities had a mean score of 12.6 (11.2, 13.8) compared to 12.0 (11.5, 12.5) in non-voucher facilities (p=450). The distribution of different cadres of staff was largely consistent with the staffing norms. However, there were variations between the voucher and non voucher facilities in the number assigned to work in maternal, child and family planning units, maternity or comprehensive care clinics. Out of the 13 FP services usually available, most facilities offered an average of 10, with services such as male and female sterilization being offered in scheduled times. Voucher facilities invested the reimbursed monies in structural features such as renovations of labor wards, employing casual laborers and repair of essential equipment. Process quality scores indicated that of the 201 providers interviewed, a third had received updates and training on contraceptive technology and FP services in the previous year with no differences between voucher and non-voucher facilities. Sixty three percent and 56.2% of providers had correct knowledge on types of hormonal contraceptive in voucher and non-voucher facilities respectively; p=0.378. However, there were low knowledge levels on how contraceptives work with 14.1% and 13.7% of providers from voucher and non-voucher facilities respectively having correct knowledge. In terms of process, in 30.9% of observations in the voucher facilities, providers build rapport adequately compared with 32.4% in the non-voucher sites, p=0.795. History taking was poor with 6% of the providers from the voucher sites taking history adequately compared to 2.9% from the non-voucher facilities, p=0.319. About a third of all providers emphasised one FP method with those from voucher sites emphasising implants (80%) compared to none at non-voucher sites. In 78% of the client interviews, clients mentioned their preferred methods of which 80% received their preference, most of them being injectables.
The assumption that reimbursement of services provided by accredited facilities will motivate providers to improve quality of service is unlikely to be realised in the short term. Facilities tend to invest money reimbursed from the program in structural features which may take time to trickle down to better service provision at client-provider level. This reflects a need to improve accreditation procedures to take account of technical competencies of providers in addition to the structural features that are often used.
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